Table 6.

Reasons cited by key informants on the widespread use of sodium valproate in women of childbearing age and pregnant women

1. VPA and lamotrigine are very effective treatments for both focal and generalised forms of epilepsy, and represent a valuable therapeutic option for both epilepsy and mood disorder patients 2. VPA and lamotrigine have a better drug interaction profile compared with phenytoin and carbamazepine, and hence are safer to use in HIV-infected patients receiving antiretroviral therapya 3. Lamotrigine requires more intensive clinical management as it must be titrated slowly (6–7 weeks) to the therapeutic dosage to reduce the likelihood of serious skin reactions. This increases the burden on the healthcare system by increasing patient visits with limited specialist and therapeutic monitoring resources 4. Any interruption in therapy (i.e. in the case of non-compliance or in the event of stock-outs) requires lamotrigine titration to be re-initiated, resulting in a risk of breakthrough seizures as well as the need for additional treatment, facility visits and monitoring 5. The impact of switching treatment on quality of life and seizure control in epilepsy patients is significant—a patient is not allowed to drive or operate heavy machinery for 1 year after any treatment switch, even if the patient has remained seizure-free. In addition, during the switchover period, there may be a greater risk of breakthrough seizures, which are also associated with risks to both the mother and the foetus 6. Mood disorder patients are often non-adherent, and concerns were raised about the mood-stabilising effects of alternative agents available in the public sector in South Africa, including antipsychotics and lithium 7. Lithium use for mood disorders in pregnancy is also challenging given its narrow therapeutic range, and hence the need for careful dose titration and monitoring during pregnancy and the increased perceived risk of congenital disorders such as Ebstein’s anomaly following in utero exposure 8. At the time of these consultations, access to the safer alternative AED, levetiracetam, was restricted to specialist use at tertiary hospitals due to prohibitive costs 9. Information on the performance of levetiracetam in South African patients is limited. Referral links between neurology and psychiatry, and women’s health services such as family planning and antenatal care are not always optimal and could be strengthened. This is to ensure that women receive adequate family planning and utilise effective contraception when prescribed VPA

VPA sodium valproate, AED antiepileptic drug, ART antiretroviral therapy

^aKnown interactions between efavirenz and carbamazepine, phenytoin and phenobarbital, through cytochrome P450 system induction. VPA has no inducing effects on ART metabolism but has been shown to displace protein binding of the antiretroviral dolutegravir, which is not clinically important as it does not change the free, active dolutegravir concentrations. Levetiracetam is not metabolised by the cytochrome P450 system as it is eliminated unchanged in the urine after undergoing enzymatic hydrolysis [20]